Published 10:22 pm, Saturday, December 27, 2014

Train engineer William Rockefeller, known as "Billy" to the regulars on Metro-North's Hudson Line, "came stumbling" into a scene of chaos in Car No. 1 after last year's disastrous derailment in the Bronx, N.Y.

The National Transportation Safety Board would later conclude that Rockefeller had fallen asleep, allowing the train to approach a curve at more than 50 mph over the safe speed, due to severe undiagnosed sleep apnea aggravated by a recent schedule change.

Passenger James Stillman gathered his belongings and fled through heavy brush to the Spuyten Duyvil station, about 100 yards away, according to interview transcripts released by the National Transportation Safety Board. Later, he offered an analysis that the NTSB would largely agree with.

More Information

Sleep apnea is a disorder in which breathing stops for short intervals during sleep. That can lead to daytime drowsiness and attention deficit besides serious health consequences for apnea-sufferers.

"There's always going to be an element of human failure involved in day-to-day operations like this," he told investigators, "and the only way to keep it up, in my opinion, is to have programs in place to keep people constantly alerted."

In this case, the human element is a basic one -- the need for sleep. But regulations governing fatigue and sleep disorders are nonexistent, despite NTSB recommendations to the Federal Railroad Administration for more than a decade and a 5-year-old federal law directing the FRA to write regulations.

Investigators asked another Metro-North engineer, Robert Butcher, if he had ever been given any information on dealing with fatigue. He replied in a word -- no, according to transcripts.

On Dec. 15, more than a year after the crash, Metro-North announced a pilot project under which its more than 400 engineers, will be screened for sleep disorders.

The Federal Railroad Administration is a different story. With an emphatic "unsatisfactory," the NTSB this fall closed the file on earlier sleep-related recommendations that the FRA had ignored and issued yet another -- and stronger -- set of recommendations to federal regulators. The FRA has yet to act, and so the NTSB says it will present its safety recommendations directly to individual railroads, unions and their associations.

"It's a real frustration that we're not seeing action from the regulator and have to go to Plan B," Christopher Hart, the NTSB acting chairman, said in an interview.

"Our approach is going to have to be railroad-specific if the FRA is not going to do it. But certainly, the most desirable result is for the FRA to do it and create a level playing field for everybody," he said.

The safety agency may need to rely on its Plan B, given that the FRA continues to ignore 63 of its recommendations to reduce risk, records show.

Asleep at the wheel

A Hearst Newspapers investigation of the Metro-North crash shows a pattern of FRA failures despite dozens of fatigue-related accidents. Among the findings:

Since the mid-1970s, the FRA has received more than 70 accident reports citing "employee asleep" as the cause, according to a review of accident data. Yet the agency's most tangible achievement thus far may be a website for railroaders offering tips on staying awake.

The FRA has repeatedly been reluctant to challenge the railroad industry it regulates, and its collaborative approach has been ineffective. The agency failed to issue regulations related to medical screening and sleep problems after industry-labor panels it created twice failed to agree on wording.

"Why hasn't the FRA acted?" U.S. Sen. Richard Blumenthal, D-Conn., asked rhetorically. "I think it's plainly and simply regulatory capture. They have been too cozy, too close to the industry and too heavily influenced by railroaders and industry executives who have obfuscated issues that should be very clear."

It can be difficult to detect employees' sleep disorders because of the nature of railroading and rights of privacy.

In the freight industry, locomotive engineers are on call at odd hours, and in passenger railroads they work early and late and sometimes split their shifts.

As Hart observed, "All the commercial transportation we look at is 24/7. Humans aren't 24/7, so right there is a disconnect."

Widespread fatigue

The NTSB spells out risk factors for obstructive sleep apnea, among them obesity, snoring and large neck and hip circumference. Rockefeller, 5-foot-11, weighed 261 pounds three days after the accident and had weighed 274 pounds the previous May. An evaluation after the wreck also said he snored.

Apnea is a disorder in which breathing stops for short intervals during sleep. That can lead to daytime drowsiness and attention deficit, in addition to serious health consequences for apnea sufferers. Yet railroad workers often aren't eager to disclose such ailments.

"People get old in the workplace," said Risch, who was an engineer for 30 years. "All of a sudden you would have these incredible standards that could cut you off just before retirement. Sleep apnea doesn't mean we have to change the whole industry."

The NTSB has issued five recommendations since 2009 calling for medical screening of "safety-critical" employees for sleep apnea. Because they haven't been followed, conditions like Rockefeller's go undiagnosed.

Newly compiled data from the FRA shows lurking danger: 8.4 percent of passenger locomotive engineers and conductors responded "yes" in a confidential survey when asked if they had sleep apnea -- more than twice the prevalence in the United States population.

Railroading nightmares

In 1990, the NTSB put fatigue management on its list of Most Wanted Safety Improvements. A year later, the safety agency concluded that the entire four-person crew of a train had been asleep or too sleepy to avoid a spectacular crash near Corona, Calif.

In 1995, at 9 o'clock on a Monday morning in June, a collision of two New York City subway trains on the Williamsburg Bridge killed motorman Layton Gibson and injured 69 passengers. Gibson, driving the Manhattan-bound J Train, died instantly when his train plowed into the stopped M Train.

Investigators said Gibson had been asleep, a conclusion they reached given the position of his body -- still in the seat with no indication he tried to hit the brakes. He had been reprimanded previously for sleeping in a darkened crew room. The conductor, who confessed to fatigue himself, told investigators that Gibson had told him he'd gotten "only a couple of hours sleep" before going on duty just before midnight.

In 2001, the crash of two freight trains near Clarkston, Mich., prompted the NTSB to turn up the pressure. Two crew members from one train died when the other train missed a red signal. Investigators learned that the engineer of the second train -- who had worked 12 straight 12-hour days -- had sleeping problems characterized by "chronic snoring with episodic awakening and daytime somnolence," his physician had written. The engineer didn't seek treatment.

After the accident, the safety agency issued three recommendations to the FRA related to the medical fitness of railroad workers in sensitive jobs, among them requiring new medical examination forms that include questions about sleep problems.

Federal law gives the FRA authority to issue rules and set standards "for all areas of railroad safety." But when it comes to fatigue and sleep, correspondence over the years suggests that the FRA has sought reasons not to use that authority.

Allen Rutter, who headed the FRA in the George W. Bush administration, argued in a letter to the NTSB in 2003 that his agency's authority in matters of employee fitness matters was limited to vision, hearing and abuse of alcohol and drugs.

Writing regulations aimed at other medical issues would be "a very demanding area of work for any regulatory agency and one that can consume substantial resources," he wrote.

The NTSB wrote back that had the FRA required screening for sleep disorders, the fatal train wreck in Michigan could have been avoided.

In 2003, the FRA did what it has done at least five times: order a study on sleep problems. The report by a Massachusetts consulting firm came back in 2005 with a recommendation to expedite development of a medical program.

Studies, committees and red tape

The FRA did what it often does with potentially unpopular regulations. It convened its Railroad Safety Advisory Committee, made up of more than 50 industry and labor representatives.

No law requires the committee. But the FRA nonetheless set it up during the Clinton administration for what was described as a collaborative process for regulations.

The system enables potentially valuable sharing of views. But, skeptics say, the cumbersome process gums up rulemaking and leads to diluted regulations.

In dealing with Positive Train Control, a computer technology that could have prevented the Bronx crash, the advisory committee took seven years to propose a regulation that was voluntary only. The FRA finally wrote a real regulation on orders from Congress. But only a handful of railroads are expected to meet next year's installation deadline after years of delay.

Steven Ditmeyer, a former director of the FRA's Office of Research and Development, recalled his frustration with the Railroad Safety Advisory Committee. "They can't say 'Don't write this regulation,' but what they can do, and have done in the past, is slow-roll it," said Ditmeyer, a transportation consultant in Washington.

In 2006, the advisory committee under FRA directions set up a Medical Standards Working Group to deal with issues such as sudden incapacitation of engineers. But no agreement was ever reached on wording for a regulation.

In 2011, an engineer and a conductor died in the crash of their coal train near Red Oak, Iowa. The NTSB reported that both had fallen asleep due to irregular work hours and fatigue from medical conditions. The engineer 5-foot-7 and 228 pounds, had been prescribed a variety of medications. The female conductor, 5-foot-4 and 221 pounds, took pills for insomnia.

The NTSB observed that had the FRA followed the safety agency's recommendations, both would have been identified as at high risk for sleep disorders.

In 2011, the FRA again put the question to its advisory committee, which set up a Fatigue Management Plan Working Group. It took two years for this panel to get far enough along to schedule a vote by the full committee in August 2013. But the vote was canceled after an 11th-hour dispute over wording. meeting minutes show. The group disbanded.

Four months later, the Metro-North crash occurred in the Bronx, injuring more than 60 passengers in addition to the four fatalities.

The FRA noted that a regulation limiting workers' hours ordered by Congress has improved safety and says its advisory committee provided valuable assistance in matters related to fatigue. But the agency declined to provide a status report for completing a regulation that will help identify sleep disorders.

"Our goal is to reduce the likelihood of accidents, injuries and fatalities caused by fatigue," the FRA said in emailed responses to questions.

Meanwhile, the accidents keep happening. Two months after the Metro-North accident, a sleeping subway operator at Chicago's O'Hare Airport overshot the station and ran her eight-car train up an escalator.

Hart, the NTSB's acting chairman, was so frustrated with the FRA in a public hearing on Metro-North this fall that he wondered aloud what other "safety gaps" exist because of the lack of oversight.

"It has been worse in railroads than any other mode of transportation," he said.